Jonathan Zuckerman MD PhD

Bx for nephrotic syndrome in an IV drug user with multiple infections. LM was all medulla, but good enough to make a diagnosis. AA amyloidosis; very common bx result in this clinical setting. #renalpath #pathsky #nephsky

sure

Bx for new onset NS in an older adult. Serologic work up including SPEP/UPEP IFE negative. Bx shows membranous pattern with few double contours. IgG3-k restriction and mottle EM deposits c/w PGNMID with membranous predominant pattern. PLA2R- #renalpath #pathsky #nephsky

Kidney txp biopsy for AKI (~6 post txp). Tubular injury associated with granular and ropey trichome positive casts. IHC confirmed myoglobin cast nephropathy. CK found to be very high; thought to be due to statin related myopathy. #renalpath #pathsky #nephsky

Heavy Chains, Heavy Consequences: A Case of Concomitant Heavy Chain Amyloidosis and Heavy Chain Deposition Disease. Fibrils and powdery deposits. #renalpath #nephsky #pathsky www.sciencedirect.com/science/arti...

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Also some rare myelin figures in a podocyte, because why not. #renalpath #nephsky #pathsky

Multiple diagnoses not uncommon in kidney biopsies. This case showed nodular diabetic nephropathy, a mostly chronic ANCA associated GN, and to top it off some interstitial ALECT2 amyloidosis. #renalpath #nephsky #pathsky

Lupus nephritis case with prominent podocyte cytoplasmic vacuolization on LM with myelin figures revealed by EM. Probably HCQ effect but given its prominence genetic etiologies should be excluded (e.g., Fabry, LMX1B). #renalpath #pathsky #nephsky

Interesting case of AL-amyloidosis. Massive vascular deposits, even in hilar arterioles with glomerular sparring. Patient had minimal proteinuria given lack of glomerular amyloid. #renalpath #pathsky #nephsky

toluidine blue stained section was also quite pleasing. #renalpath #pathsky #nephsky

Nice example of urate crystals in gouty tophi involving the medulla. Polarizable crystals can be see using unstained sections from the IF tissue. #renalpath #pathsky #nephsky

Another example of an 'incidental' finding next to the tumor in a nephrectomy specimen. Amyloidosis (probably LECT2). Reminder not too overlook the non-neoplastic tissue. #renalpath #pathsky #nephsky

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Multi-focal severe necrotizing arteritis in a kidney biopsy with an ANCA vasculitis. Interestingly, foci of arteritis were only present in IF/EM tissue. Illustrating how even when severe arteritis can be easily missed due to sampling in a small biopsy. #renalpath #nephsky #pathsky

Microscopic Tubulovenous Communications in Nonneoplastic Kidneys: A Single-Center Case Series and Review of the Literature Pathological connection between the kidney tubules and veins is known as a microscopic tubulovenous communication we refer to as a tubulovenous fistula (TVF). This finding has been reported in a few s...

Great work by our chief resident @clilleymd.bsky.social on charactering microscopic tubulo-venous communications in kidney biopsies. www.kidneymedicinejournal.org/article/S259... . Here's another nice example (x.com/JZRenalPath/...) #renalpath #pathsky #nephsky

Kidney txp biopsy with histologic features of acute pyelonephritis. Neutrophilic tubulitis, neutrophilic casts, and tubules which seem to explode out. Cellular rejection typically is not neutrophilic and inflammation hits the tubules from the outside in. #renalpath #nephsky #pathsky

these are the areas I am referring to in the EM in one image. Not super specific, but could be the correlate for your IF staining.

or perhaps secondary overload injury from an original membranous nephropathy that has long resolved with just some IC staining. This is the best way I can put this together, but just my opinion. I agree this is not a typical case.

Given the GBM thickening and maladpative glomerular injury(hypertrophy), the IC staining may be incidental at this time and the patient's dx is mostly overload injury. Is the patient obese, have diabetes, HTN, smoking, MPN, low bithweight, etc.?

despite being much weak in reality. The GBM in the EM images do seem to show some undulation of the subepithelial surface which may be a subtle clue to some small mostly resorbed subepithelial deposits. So we may be seeing minimal residual subepithelial deposits from prior disease.

GBMs looks thick, you also mention glomerular hypertrophy. Wonder if some of the staining you see in the capillary loops is just "pseudolinear" IgG as we see in diabetic glomerulopathy and other metabolic dx associated glomerulopathy. Perhaps the small granular deposits are being enhanced here.

Can you post some of the EM images. Did you have conventional EM not just re-processing on the frozen?

"stage 0" membranous nephopathy can occur. Typically this seen early in recurrent MN in transplants. but I am very surprised by the EM discrepancy in this case. Can you clarify the clinical situation for the biopsy?

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Wide variety of morphologies in this case of crystalline light chain proximal tubulopathy: mottle lysosomes, crystals, and fibrils. #renalpath #nephsky #pathsky

One of the more subtle amyloid cases I have seen. Just a few deposits in 2 gloms by LM. Just enough congo red staining. Glad to catch it in the EM as well. #renalpath #nephsky #pathsky

Thank you. I am fortunate to have an excellent histology lab. The staining is mostly done on the grid (Uranyl acetate/ lead citrate). Osmium tetroxide is used in block preparation which also provides some contrast.

Some well formed "eye lashes" on these capillary loops in a case of AL-amyloidosis. Podocytes getting skewered by the spicules in the EM. #renalpath #pathsky #nephsky.